Manejo de La via Aerea en Prehospitalario

7/27/2019 Manejo de La via Aerea en Prehospitalario

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Dr. Alan Bazn Farfn


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Anestesilogo

Jefe SAMU

Regin de Los Lagos

Dipl. GestinInstituciones deSalud

Dipl. MedicinaAeroespacial

Sin conflicto deintereses


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El paciente no se muere porque no fueintubado, sino porque no fue oxigenado


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Con estas maniobras se

obtiene la permeabilidad dela va area en el 97% de los

casos


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Caractersticas Consecuencias

Estmago lleno

Potencial dao columnacervical

Mala iluminacin y trabajoen espacios confinados

Dao multisistmico

Mltiples vctimas

Riesgo Aspiracin Pulmonar

Dificultad manejo V.A.

Dificultad manejo V.A.

Morbilidad por desconocercondicin real del dao

Morbimortalidad porrecursos insuficientes


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Profesionales universitarios no mdicos Cumplen labores propias de la formacin mdica:

Diagnstico Decisin

Manipulacin y colocacin de dispositivos en va area Administracin de frmacos Etc.

Competencias no entregadas en sus mallascurriculares de pregrado

Cdigo Sanitario


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ATLS Intubacin Endotraqueal y proteccincolumna cervical ASA

Medicina Basada en la Evidencia:

RCP: 5:1 15:2 30:2 200:2 ????

Guas RCP AHA 2005: la experiencia con dispositivos avanzados para la va area muestra claramenteque la intubacin traqueal realizada por personal inexperto puede asociarsecon alta tasa de complicaciones

Guas AHA 2010: Nos cambia el A B - C por C A B RCP mnimas interrupciones


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1. IOT interrumpe el aporte de Oxigeno durante la RCP

2. Uso de hipnoinductores y BNM. Riego/beneficio llegar a no puedointubar, no puedo ventilar3. 2 ms intentos fallidos de IOT, traumatiza va area,

edema y sangrado dificultad progresivahasta prdida de la ventilacin Bolsa-Mscara

4. A mayor expertice del personal en manejo de la va area, mayorsobrevida y outcome del paciente

5. La sobrevida de los pacientes crticos es similar en aquellos IOT y losventilados Bolsa mscara

Benumof JL, Anesthesiology 1991:75: 1087-1110Practice Guidelines for Management of the Difficult Airway. Anesthesiology 1993:78:597-602An update report by ASA Task Force Management of the Difficult Airway. Anesthesiology2003:95: 1269-1277


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Nivel de educacin y entrenamiento necesario parael uso seguro de una tcnica especfica.

La herramienta correcta en las manos correctas


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EntrenamientoBsico:

Pocket maskVentilacin Bolsa MascarillaTENS

EntrenamientoIntermedio:

Pocket MaskVentilacin Bolsa MscaraDispositivos SupraglticosReanimadores-Mdicosgenerales

EntrenamientoAvanzado:Ventilacin Bolsa MscaraDispositivos SupraglticosIOTIOT ISRMdicos entrenadosEspecialistas

Berlac P, Hyldmo PK, Kongstad P, et A l.Pre-Hospital airway management guidelines a taskforce from Scandinavian Society for Anaesthesiologyand Intensive Care Medicine.Acta Anaesthesiol Scand 2008; 52: 897-907


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1. Cnulas farngeas

2. Mscara facial

3. Mscara larngea

4. Tubos endotraqueales


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Fcil aprendizaje Distensin gstrica

Regurgitacin

Kurolan JO, Turunen MJ, Laakso JP et al. Acomparison of the laryngeal tube and bag-valve mask ventilation by emergencymedical technicians: a feasibility study inanesthetized patients. Anesth Analg 2005;101: 1577-81

Doerges V, Sauer C, Ocker H et al. Airwaymanagement durin cardiopulmonaryresuscitationa comparative study of bag-valve-mask, laryngeal mask airway andcombitube ina a bench model.Resuscitation 1999; 41: 63-9

Stone BJ, Chantler PJ, Baskett PJ.The incidence of regurgitationduring cardiopulmonaryresuscitation: a comparinsonbetween the bag valve mask andlaryngeal mask airway.Resuscitation 1998; 38: 3-6.


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Brain AIJ, Verghese C, Addy EV, Kapila A. The intubatinglaryngeal mask, I: development of a new device for intubationof the trachea. Br. J Anasth 1997; 79:699-703.


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Davies PR, Tigue SQ, Greenslade GL etal. Laryngeal mask airway and trachealtube insertion by unskilled personnel.Lancet 1990; 336: 977-9.

Pennant JH, Walker MB. Comparision ofthe endotracheal tube and laryngealmask in airway management byparamedical personnel. Anesth Analg1992: 74: 531-4.Martin PD, Cyna AM, Hunter WA et al.Training nursing staff in airwaymanagement for resuscitation. Aclinical comparision of the facemaskand laryngeal mask. Anaesthesia1993; 48: 33-7.


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97% xito 1 intento

Kurola J, Pere P, Niemi-Murola L et al.Comparison of airway mangement withthe intubating laringeal mask, laryngealtube an Cobra PLA by paramedicalstudents ina anaesthetized patients.Acta Anaesthsiol Scand 2006; 50:40-4.


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Brain AIJ, Verghese C, Strube PJ. TheLMA ProSeal- a laryngeal mask withan oesophageal vent.Br. J Anasth 2000; 84:650-654.

Evans NR, Gardner SV, James MFM, ProSeal laryngealmask protects against aspitration of fuid in thepharinx.Br. J Anaesth 2002; 88: 584-587.

No recomendado por la Task Force Sacandinavian pormayor dificultad de insercin frente a cLMA


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Ferson DZ, Chi L, Zambare S Brown D. The effectiveness of the LMA Supreme in patients withnormal and difficult to manage airway. Anesthesiology 2007; 107: A 592Pearson D, Young P. Use of the LMA- Supreme for airway rescue.Anesthesiology 2008; 109: 356-357.Timmermann A . Cremer S. Heuer J, et al. Laryngeal mask LMA Supreme. Application bymedical personnel inexperienced in airway management. Anaesthesist 2008; 57: 970-975.


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Drges V, Ocker H, Wenzel V et al. TheLaryngeal Tube S: a modified simple airwaydevice.Anesth Analg 2003; 96: 618-621.

78-100% xito en paciente anestesiadoKurolan JO, Turunen MJ, Laakso JP et al. A comparison of thelaryngeal tube and bag-valve mask ventilation by emergencymedical technicians: a feasibility study in anesthetized patients.Anesth Analg 2005; 101: 1577-81

83% xito en PCRKette F, Reffo I, Giordani G et al. The use of laryngeal tube bynurses in out of hospital emergencies: preliminary experiences.Resuscitation 2005; 66: 21-5


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Ningn estudio, ctedra , fabricante u opinin deexpertos avala su insercin en pacientes conreflejos de va area presentes.

Aumenta riesgo de nuseas, vmitos y aspiracin.

Laringoespasmo.


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Gold Standard fcil o exento de riesgo

Intubacin esofgica no detectada

Ambiente prehospitalario desplazamiento TOT


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En contra A favor

Gausche M, Lewis RJ, Stratton SJ et al. Effect ofout of hosp ital pediatric endotrachealintubation on survival and neurologicaloutcome : a controled clinical trial. JAMA2000; 283: 783-90. Davis DP, Dunford JV, Poste JC et al. Theimpact of hypoxia an hyperventilation onoutcome after paramedic rapid sequenceintubation of severely head injured pa tients. J

Trauma 2004; 57:1-8. DiRusso SM, sullivan T, Risucci D et al.Intubation of pediatric trauma patients in thefield: predictor of negative outcome despiterisk stratification. J trauma 2005; 59: 84-90. Bochiccio GV, Ilahi O, Joshi M et al.Endotracheal intubation in the field does notimprove outcome in trauma patienst whopresent without an acutely lethal traumaticbrain injury. J trauma 2003 , 54: 307-11

Klemen P, Grmec S, Effect of prehospitaladvanced life support with rapidsequence intubation on ou tcome ofsevere traumatic brain injury. ActaAnaesthesiol Scand 2006; 50: 1250-4


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53-63% IOT exitosa Intubacin esofgica no advertida:

6- 16,7 % 37 %Rocca B, Crosby E, M aloney J et al. An assessment of paramedic perfomance duringinvasive airway mangement. Prehosp Emerg Care 2000; 4: 1350-7Wang HE, Sweeney TA, OConnor RE et al. Failed prehospital intubations: an anlysis ofemergency department courses and outcomes. Prehosp Emerg Care 2001; 5: 134-41Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergencymedical services system. Ann Emerg Med 2001; 37: 32-7.


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99,1% xito Intubacin esofgica no advertida:

0,4 %

8% uso BNMN= 691

Adnet F, Jouriles NJ, Le TP et al. Survey of out of hosp ital emergency intubations inthe French prehospital medical system: a multicenter study. Ann Emerg Med 1998;32: 454-60.N= 147 nios Meyer G, Orliatguet G, Blanot S et al. Complications of emergency trachealintubation in severely head injury children. Paediatr Anaesth 2000; 10: 253-60.


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xito 62,5 85% Wang HE, OConnor RE, Megargel RE et al. The utilization of midazolam as apharmacolologicadjunct to endotracheal intubation by paramedics. Prehosp EmergCare 2000; 4: 14-8. Dickinson ET, Cohen JE, Mechem CC. The effectiveness of midazolam as a

pharmacologic agent to facilitate endotracheal intubation by paramedics. PrehospEmerg Care 1999; 3: 191-3

Sedacin insuficiente: Aumento PIC

Taquicardia

Reflejos va area

Mayor dao en TEC

Isquemia miocrdica

LaringoespasmoBroncoespasmo

VmitoAspiracin


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Produccin de CO2 Perfusin pulmonarVentilacin alveolar Patrn respiratorioPosicin TOT Gasto Cardaco

Donald MJ, Paterson B. End tidal carbon dioxide monitoringin prehospital and retrieval medicine: a review.Emerg Med J 2006; 23:728-30


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Reduce el riesgo de hiper o hipoventilacininadvertida.

Helm M, Schuster R, Hauke J et al. Tight control ofprehospital ventilation by capnography in major traumavictims. Br j Anaesth 2003; 90: 327-32.

PaCO2 Flujo Sanguneo Cerebral Presin IntraCraneana


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Paciente

Operador

Dispositivos


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Manejo de La via Aerea en Prehospitalario

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